Youth Program Registration Name of Program Child's Name * First Name Last Name Child's Age * Parent/Guardian #1 Name * Parent/Guardian #1 Phone * (###) ### #### Parent/Guardian #2 Name (if applicable) Parent/Guardian #2 Phone (if applicable) (###) ### #### Best Parent/Guardian Email Address (i.e. who would you like to receive notifications?) * Best Parent/Guardian Mailing Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Medical Release Information Emergency Contact * First Name Last Name Emergency Contact Phone * (###) ### #### Does this participant have any known allergies, medications, physical limitations, emotional challenges (learning style, psychological or social needs, conditions or challenges fears, English as second language, loss in family, etc.)? * Yes No If you answered yes, please use this space to explain. Does your child have any dietary restrictions? * If so, please describe. Photo Use Permission * Do we have permission to utilize still or motion picture images of your child participating in their programs or events for outreach purposes, including but not limited to electronic or print materials, or print or broadcast media? Yes No Waiver of Liability * Waiver of Liability: I certify that the information provided on this form is true and accurate. I agree that my enrolled child will adhere to safety instructions and will wear appropriate clothing and safety equipment as directed by the instructors. While I fully understand that some class activities could result in personal injury, I assume the full risk of injury as a result of my enrolled child’s participation in any course or activities at or conducted by CedarRoot. This includes injury caused by the negligence of other participants. Myself, my heirs, executors, administrators and assigns forever release CedarRoot, its officers, directors, agents, employees, teachers and landlords from all liability, claims, demands, actions, causes or action, of whatever type or nature, for any injury to my enrolled child’s person arising from their enrollment or participation. PLEASE SELECT "I agree." PARENT/GUARDIAN, YOU ARE SIGNING FOR YOUR MINOR CHILD. I agree I do not agree How did you hear about us? Flyer Website Long term CedarRoot fan! Other SUMMER CAMP ONLY: T-shirt size Not applicable X-small Small Medium Large X-large Thank you!
